Summary Care Record Opt-Out Form

Request for my clinical information to be withheld from the Summary Care Record

If you DO NOT want a Summary Care Record, please complete this form. If you are completing this form on behalf of another person or child, please ensure you provide their details in section A and your details in section B.

1 Patient's Details

Titleplease specify

First Name(s)

Surname

Home Address

Postcode

Telephone Number

NHS Number (if known)If you know your NHS Number, please provide it

Date of BirthPlease provide in the format DD/MM/YYYY

2 Carer's Details

First Name(s)

Surname

Relationship to patient

Further Information

What does it mean if I DO NOT have a summary health care record?

NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency.

Your records will stay as they are now with information being shared by letter, email, fax or phone.

If you have any questions, or if you want to discuss your choices, please phone the Summary Care Record Information Line on 0300 123 3020; contact your local Patient Advice Liaison Service (PALS); or contact the practice.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form toYorkleigh Surgery
•
93 St George's Road, Cheltenham, Gloucestershire, GL50 3ED.

Learn more about our Privacy Policy and
Terms of Use.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.